Catalyst Center Coverage
Roundup of news related to financing of care for children and youth with special health care needs |
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Quote of the Week
"Before you criticize someone, you should walk a mile in their shoes. That way when you criticize them, you are a mile away from them and you have their shoes."
~ Jack Handey |
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Featured Article
NHeLP: National Health Law Program
September 24, 2013
The Florida Agency for Health Care Administration determined that Applied Behavioral Analysis (ABA) was an experimental treatment for children diagnosed with Autism Spectrum Disorders (ASDs). As such, the agency denied payment for this therapy because it was not medically necessary, and therefore not included in the federally mandated Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefit. In March 2012, U.S. District Judge Joan Lenard decided in favor of the families who sued the agency. She ruled that ABA was an evidence-based treatment for children diagnosed with ASDs and ordered Florida Medicaid to provide ABA as part of the EPSDT benefit. The Agency for Health Care Administration appealed the decision. On September 20, 2013, the U.S. Court of Appeals for the Eleventh Circuit upheld Judge Lenard's ruling. This has important implications, both in the state of Florida and nationally. While Florida does provide ABA through a Medicaid waiver, there can be waiting lists for waiver services. This ruling makes it possible for any child younger than 21, enrolled in Medicaid, and for whom ABA is considered medically necessary, to receive this therapy without waiting for a waiver slot. Nationally, 34 states and the District of Columbia (D.C.) have Autism insurance laws that mandate certain private health insurers to provide ABA. The Florida ruling has the potential to close the gap in services and improve outcomes for children with ASDs who rely on Medicaid as their sole form of coverage.
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 IN THIS ISSUE
News Items
Resources
Events and Announcements
In Case You Missed It...
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Catalyst Center Coverage?
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News Items
By Michael Ollove
Stateline: The Daily News Service of The Pew Charitable Trusts
October 24, 2013
Habilitive services - services that help individuals develop skills they never had - are particularly important for children and youth with special health care needs who may, for example, need physical or speech therapy to learn to walk or talk. Once considered educational, habilitative services were the responsibility of the schools. Since 1989, Medicaid has included habilitative services as a benefit. Some states have also mandated private health plans to cover habilitation. In January 2014, a provision of the Affordable Care Act (ACA) will require every health plan sold through the health insurance marketplaces as well as new plans sold in the individual and small-group market to provide 10 essential health benefits, which includes rehabilitative and habilitative services. While this is good news, concerns remain. Health plans cannot impose lifetime benefit caps, but they can still limit the number of therapy visits. In addition to defining the amount, scope, and duration of these services, some plans may combine habilitative and rehabilitative services.
By Michelle Diament
Disability Scoop
October 15, 2013
Every health plan sold through the health insurance marketplaces, as well as new plans sold in the individual and small group market must provide 10 essential health benefits. Mental health and substance use disorder services, behavioral health treatment, counseling, and psychotherapy is one of the essential health benefits categories. Considered by some to be a behavioral health treatment, advocates are concerned that Applied Behavioral Analysis (ABA) will be covered in only 26 states and the District of Columbia. Because each state uses one of four types of benchmark plans to define the amount, scope, and duration of the services offered in each of the ten categories, services will vary by state. In addition, some states mandate certain types of private insurance to provide ABA. However, if the benchmark plan is exempt from state laws and mandates, ABA may not be a covered benefit in a state's marketplace, individual, and small-group health plans. [Explore the Catalyst Center State-at-a-Glance Chartbook to see which states mandate private insurance benefits that are important for children and youth with special health care needs.]
Prepared by Wayne Turner
Health Advocate: the E-Newsletter of the National Health Law Program
October 2013
Does having health insurance mean that individuals receive needed care? In an effort to ensure that children who are enrolled in Medicaid are screened for potential and preventable health problems and receive needed treatment, Congress created Early and Periodic Screening, Diagnosis and Treatment (EPSDT), a federally mandated Medicaid benefit for children, birth to 21. EPSDT ensures that children receive all medically necessary services, even if one or more of those services are not part of the state's adult Medicaid benefits. This article provides an overview of the challenges of implementing EPSDT, state reporting requirements, due process protections, and the lawsuits advocates have filed in states that are believed to be denying medically necessary services to children. In 2014, the Affordable Care Act (ACA) will raise the Medicaid income eligibility for children ages 6 through 18 from 100% of the federal poverty level (FPL) to 138% FPL. With more children eligible, it will be increasingly important to keep watch on how EPDST is implemented to safeguard children's health and well-being.
By Shaun Heasley
Disability Scoop
October 8, 2013The Social Security Administration and the U.S. Departments of Labor, Education, and Health and Human Services are working together on behalf of children who receive Supplemental Security Income (SSI). This joint effort, known as the PROMISE initiative (Promoting Readiness of Minors in Supplemental Security Income) provides funding for demonstration projects in selected states. Each project will provide "coordinated services and supports" to ensure children who receive SSI will be able to graduate from high school and have postsecondary and/or job training opportunities so they can enter the workforce and eventually transition off SSI. See the list of state PROMISE programs. |
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Resources
By Carolyn McCoy
Association of Maternal and Child Health Programs (AMCHP)
September 2013This fact sheet is the newest addition to AMCHP's tools to support state Title V program staff in learning about coverage options for Maternal and Child Health (MCH) populations as the Affordable Care Act (ACA) continues to be implemented. A table breaks down the coverage options for MCH populations. One column identifies potential benefit gaps, especially gaps that may affect children and youth with special health care needs. By Richard C. Adams, Carl Tapia, and the Council on Children with Disabilities
Pediatrics
September 30, 2013This report provides an overview of the benefits of pediatric medical homes and Part C Early Intervention Programs and best practices for working together to support families raising children, birth to three, with special needs. By Nicole Cafarella Lallemand, Elizabeth Richardson, Kelly Devers, and Lisa Simpson
National Evaluation of the CHIPRA Quality Demonstration Grant Program
October 2013This fourth Evaluation Highlight focuses on the strategies five CHIPRA QD (Children's Health Insurance Program Reauthorization Act Quality Demonstration) grantees used to ensure federal and state-specific reform policies did not focus solely on the health needs of adults. For example, Oregon's Coordinated Care Organizations will receive technical assistance to connect pediatric providers and early educators. Maryland is expanding its care management entities to improve quality of care for youth with behavioral issues and reduce costs. Maine worked with stakeholders to create a list of pediatric quality measures that will be included as quality measures in other initiatives, such as the Maine Health Homes program. The Child Health Quality Coalition in Massachusetts, created as part of the CHIPRA grant, brought together providers, payers, hospitals, public and private entities, families, and other stakeholders to ensure children's needs were represented in state initiatives, such as payment reform. Vermont's statewide medical home initiative now includes pediatric practices. The Henry J. Kaiser Family FoundationDepending on household income, access to employer-sponsored health insurance, and eligibility for Medicaid or Medicare, individuals and families who purchase health insurance through the marketplaces (also called exchanges) may be eligible for financial assistance. This assistance, in the form of tax credits, will be applied towards the cost of insurance premiums. Based on information you provide, the Subsidy Calculator provides estimates of the maximum percentage of household income you can expect to pay in premiums, the subsidy amount, yearly premiums based on silver plan (pays 80% of health costs), and additional information. |
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Events & Announcements
In May of this year, researchers, practitioners, policy makers, and young adults participated in a workshop hosted by the Institute of Medicine (IOM) and the National Research Council. Review the (truly awesome) infographic and download the summary of the event (free) to learn about the challenges of transition, including lapses in health care and risks of mental and chronic health conditions.
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Want more news?
To view more articles from past issues of Catalyst Center Coverage, visit the Catalyst Center website. For state-specific news, visit the Catalyst Center Facebook page.
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News to share?
If you have suggestions for news items related to coverage and financing of care for CYSHCN please email Beth Dworetzky Catalyst Center Coverage editor and Catalyst Center Project Director by 12 noon on Friday.
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The Catalyst Center is a national center dedicated to working with states and stakeholder groups on improving health care insurance and financing for Children and Youth with Special Health Care Needs (CYSHCN). For more information, please visit us at www.catalystctr.org or contact Meg Comeau, Co-Principal Investigator, at mcomeau@bu.edu.
The Catalyst Center is funded under cooperative agreement #U41MC13618 from the Division of Services for Children with Special Health Needs, Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services. Marie Mann, MD, MPH, FAAP, MCHB/HRSA Project Officer. The contents of Catalyst Center Coverage are solely the responsibility of the authors and do not necessarily represent the views of the funding agencies or the U.S. government.
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